Bracondale Medical Centre

Travel QuestionnaireIf you are travelling abroad on holiday or business you may need travel vaccinations depending on the countries you are visiting. Please complete this form 12 weeks before your trip and return it to us as soon as possible so we can offer the best and most up to date advice and we can plan your vaccination schedule of 15 min appointments.

Please note we need one form per traveller.

Name

Address

Telephone number

Date of Birth

Departure date

Duration of stay abroad

Which countries, in order are you going to visit, including even brief stopovers? please be specific.

Please state whether you will be staying in hotels, back

packing, camping or staying with friends or relatives?

Does your journey include:Costal areas? Yes / NoInland areas? Yes /No

Does your journey include any safaris, jungle exploration or travel in difficult terrain?

Have you ever had any of following vaccinations and if so when

BCG YES/NO --------Hepatitis A/B YES/NO --------Immunoglobulin YES/NO --------Influenza YES/NO --------Japanese encephalitis YES/NO --------Meningococcal YES/NO --------Rabies YES/NO --------Tick-borne encephalitis YES/NO --------Tetanus YES/NO --------Typhoid YES/NO --------Yellow Fever YES/NO --------Childhood immunisations YES/NO --------Including polio and diphtheria

Are you allergic to anything?YES/NO If yes please state

List here any medication you take?_____________________________________________________________________________________________

If you take regular medication make sure you have enough supplies with

you to last whilst you are abroad, (you are allowed to take up to 3 months supply out of the country)

Do you or have you ever suffered from heart disease or any other chronic illness?

Are you pregnant or breastfeeding?YES/NO_____________________________